FCC Form 5631 Lifeline Program Household Worksheet

FCC FORM 5631

OMB APPROVAL EDITION 3060-0819

Lifeline Program
Household Worksheet

About
Lifeline
Lifeline is a benefit that
lowers the monthly cost
of phone or internet
service (not both). You
are only allowed to get
one Lifeline benefit
per household, not per
person.

What this worksheet is for
Use this worksheet if someone else at your address gets Lifeline. The answers to these questions will
help you find out if there is more than one household at your address.

What is a household?
A household is a group of people who live together and share income and expenses (even if they are
not related to each other).

Examples of one household:

•A
 married couple who live together are one household. They must share one Lifeline
benefit.
•A
 parent/guardian and child who live together are one household. They must share one
Lifeline benefit.
•A
 n adult who lives with friends or family who financially support him/her are one
household. They must share one Lifeline benefit.

Examples of more than one household:

• 4 roommates who live together but do not share money are 4 households. They can have
one Lifeline benefit each, 4 total.
• 3 0 seniors who live in an assisted-living home are 30 households. They can have one
Lifeline benefit each, 30 total.

Household expenses
A household shares expenses. Household expenses include, but are not limited to, food, healthcare
expenses, and the cost of renting or paying a mortgage on your place of residence and utilities.

Income
Households share income. Income includes salary, public assistance benefits, social security
payments, pensions, unemployment compensation, veteran’s benefits, inheritances, alimony, child
support payments, worker’s compensation benefits, gifts, and lottery winnings.

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Universal Service Administrative Company | www.lifelinesupport.org
Need help? Call the Lifeline Support Center at 1-800-234-9473

FCC FORM 5631

OMB APPROVAL EDITION 3060-0819

Lifeline Program
Household Worksheet

Your
Information
All fields are required
unless indicated. Use only
CAPITALIZED LETTERS
and black ink to fill out
this form.

What is your full legal name?

The name you use on official documents, like your Social Security Card or State ID. Not a nickname.

First

Middle (optional)

Suffix (optional)

Last

What is your home address? (The address where you will get service. Do not use a P.O. Box)

Street Number and Name

Apt., Unit, etc.

State

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City

Zip Code

Universal Service Administrative Company | www.lifelinesupport.org
Need help? Call the Lifeline Support Center at 1-800-234-9473

FCC FORM 5631

OMB APPROVAL EDITION 3060-0819

Lifeline Program
Household Worksheet

Can you
apply?
Follow this decision tree
to confirm if you qualify
for the Lifeline Program.

1. Do you live with another adult?

Adults are people who are 18 years old or older, or who are emancipated
minors. This can include a spouse, domestic partner, parent, adult son or
daughter, adult in your family, adult roommate, etc.

Yes

No

If yes, answer
question 2

2. Do they get Lifeline?
Yes

No

If yes, answer
question 3

Check this box

3. Do you share money (income and expenses)
with them?
This can be the cost of bills, food, etc., and income. If you are married,
you should check yes for this question.

Yes

No

You do not qualify for Lifeline because someone in your household
already gets the benefit. You are only allowed to get one Lifeline
discount per household, not per person.
Check this box

Page 3 of 4

You can apply for
Lifeline. You live in a
household that does
not get Lifeline yet.
Please initial line B on
page 3, and sign and
date the worksheet.

You can apply for
Lifeline. You live at an
address with more than
one household and
your household does
not get Lifeline yet.
Please initial lines
A and B on page 3,
and sign and date the
worksheet.
Check this box

Universal Service Administrative Company | www.lifelinesupport.org
Need help? Call the Lifeline Support Center at 1-800-234-9473

FCC FORM 5631

OMB APPROVAL EDITION 3060-0819

Lifeline Program
Household Worksheet

Agreement
Please initial the
agreement below and
sign and date this
worksheet. Submit this
worksheet to your
service provider with
your Lifeline Program
Application Form.
I consent to let USAC contact me at my Lifeline
phone number for important reminders and
updates to my Lifeline service. Message and data
rates may apply. Text STOP to end messages.

A I live at an address with more than one household.
Initial

Initial

B I understand that the one-per-household limit is a Federal Communications Commission
(FCC) rule and I will lose my Lifeline benefit if I break this rule.

Signature

Today’s Date

Notice
NOTICE: Section 54.410 of the Federal Communications Commission’s rules requires all Lifeline subscribers to demonstrate their
eligibility to receive Lifeline services. If more than one person at the same address is applying for Lifeline service, all applicants
must submit a Household Worksheet. This collection of information stems from the Commission’s authority under Section 254 of
the Communications Act of 1934, as amended, 47 U.S.C. §254. Using this authority, the FCC has designated USAC as the permanent
Lifeline Administrator. The FCC has published rules detailing how consumers can qualify for Lifeline services and what Lifeline
services they may receive (47 CFR §54.400 et seq.). The data provided in response to this information collection will be used by USAC
to verify the applicant’s eligibility for Lifeline services.
We have estimated that each response to this collection of information will take, on average, 0.25 hours. Our estimate includes the
time to read and complete the form and review the form or response. If you have any comments on this estimate, or how we can
improve the collection and reduce the burden it causes you, please write to the Federal Communications Commission, OMD-PERM,
Paperwork Reduction Project (3060-0819), Washington, D.C. 20554. We also will accept your comments via the Internet if you send
them to PRA@fcc.gov. Please DO NOT SEND COMPLETED DATA COLLECTION FORMS TO THIS ADDRESS.
Remember – You are not required to respond to a collection of information sponsored by the Federal government, and the
government may not conduct or sponsor this collection, unless it displays a currently valid Office of Management and Budget (OMB)
control number. This collection has been assigned an OMB control number of 3060-0819.
The Commission is authorized under the Communications Act of 1934, as amended, to collect the information we request in this
form. We will use the information that you provide to determine your eligibility for Lifeline services. If we believe there may be a
violation or potential violation of a statute or a Commission regulation, rule, or order, your form may be referred to the Federal,
state, or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute, rule, regulation, or order. In
certain cases, the information in your form may be disclosed to the Department of Justice, court, or other adjudicative body when
(a) the Commission; (b) any employee of the Commission; or (c) the United States government, is a party to a proceeding before the
body or has an interest in the proceeding.
If you do not provide the information we request on this form, you will not be eligible to receive Lifeline services under the Lifeline
Program rules, 47 C.F.R. §§ 54.400-54.423.
The foregoing Notice is required by the Paperwork Reduction Act of 1995, P.L. No. 104-13, 44 U.S.C. § 3501, et seq.
PRIVACY ACT STATEMENT: The Privacy Act is a law that requires the Federal Communications Commission (FCC) and the Universal
Service Administrative Company (USAC) to explain why we are asking individuals for personal information and what we are going to
do with this information after we collect it.
Authority: Section 254 of the Communications Act (47 U.S.C. § 254), as amended, 47 U.S.C. §254, authorizes the FCC to operate the
Lifeline program. Using this authority, the FCC has designated USAC as the permanent Lifeline Administrator. The FCC has published
rules detailing how consumers can qualify for Lifeline services and what Lifeline services they may receive (47 CFR §54.400 et seq.).
Purpose: We are collecting this personal information so we can verify that you qualify for the Lifeline program and so we can
efficiently provide Lifeline services to you. We access, maintain and use your personal information in the manner described in the
Lifeline System of Records Notice (SORN), FCC/WCB-1, which we have published in 82 Fed. Reg. 38686 (Aug. 15, 2017).
Routine Uses: We may share the personal information you enter into this form with other parties for specific purposes, such as: with
contractors that help us operate the Lifeline program; with other federal and state government agencies that help us determine your
Lifeline eligibility; with the telecommunications companies that provide you Lifeline service; and with law enforcement and other
officials investigating potential violations of Lifeline rules.
A complete listing of the ways we may use your information is published in the Lifeline SORN described in the “Purpose” paragraph
of this statement.
Disclosure: You are not required to provide the information we are requesting, but if you do not, you will not be eligible to receive
Lifeline services under the Lifeline Program rules, 47 C.F.R. §§ 54.400-54.423.

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Universal Service Administrative Company | www.lifelinesupport.org
Need help? Call the Lifeline Support Center at 1-800-234-9473